Pacific Journal of Medical Sciences, Vol. 18, No. 1, January 2018 ISSN: 2072 – 1625 ======

PACIFIC JOURNAL OF MEDICAL SCIENCES

{Formerly: Medical Sciences Bulletin} ISSN: 2072 – 1625

Pac. J. Med. Sci. (PJMS) www.pacjmedsci.com. Emails: [email protected]; [email protected]

STATUS OF IODINE NUTRITION AMONG SCHOOL-AGE CHILDREN IN KARIMUI-NOMANE AND SINA-SINA YONGGOMUGL DISTRICTS IN SIMBU PROVINCE

*Victor J. Temple1, Guapo Kiagi2, Hethy M. Kai1, Hanifa Namusoke3, Karen Codling4, Lazarus Dawa3 and Eileen Dogimab5

1. Micronutrient Research Laboratory, Division of Basic Medical Sciences, School of Medicine and Health Sciences, University of Papua New Guinea 2. Sir Joseph Nombri Memorial-Kundiawa General Hospital, Simbu Province, Papua New Guinea 3. UNICEF Papua New Guinea; 4. Iodine Global Network; 5 National Department of Health PNG

*Correspondence to: [email protected]

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Pacific Journal of Medical Sciences, Vol. 18, No. 1, January 2018 ISSN: 2072 – 1625 ======

STATUS OF IODINE NUTRITION AMONG SCHOOL-AGE CHILDREN IN KARIMUI-NOMANE AND SINA-SINA YONGGOMUGL DISTRICTS IN SIMBU PROVINCE PAPUA NEW GUINEA

*Victor J. Temple1, Guapo Kiagi2, Hethy M. Kai1, Hanifa Namusoke3, Karen Codling4, Lazarus Dawa3 and Eileen Dogimab5

1. Micronutrient Research Laboratory, Division of Basic Medical Sciences, School of Medicine and Health Sciences, University of Papua New Guinea 2. Sir Joseph Nombri Memorial-Kundiawa General Hospital, Simbu Province, Papua New Guinea 3. UNICEF Papua New Guinea; 4. Iodine Global Network; 5 National Department of Health PNG

*Correspondence to: [email protected]

ABSTRACT: Iodine deficiency is regarded as the single most common cause of preventable mental impairment in communities with suboptimal intake of iodine. Universal Salt Iodization is the most effective and sustainable intervention strategy for prevention, control and elimination of iodine deficiency. Urinary iodine concentration is the biochemical indicator for assessing the iodine status of a population. This study was prompted by reports showing evidence of cretinism in Karimui-Nomane district in Simbu province. The major objectives were therefore to assess the availability of adequately iodized salt in households, the per capita discretionary intake of salt per day and the iodine status of school children (age 6 – 12 years) in Karimui-Nomane, the district of concern, and Sina Sina Yonggomugl, a comparison district in Simbu province. Iodine level was assessed in salt samples collected from randomly selected households in both districts. The head of each household completed a questionnaire on knowledge, attitudes and practices related to salt iodization. Urinary iodine concentrations were measured in spot urine samples collected from randomly selected 6 to 12 years old children from selected primary schools in the two districts. 82.4% and 63.8% of salt samples from Karimui-Nomane and Sina Sina Yonggomugl respectively were adequately iodized above the national standard of 30ppm. The mean per capita discretionary intake of salt in households in Karimui-Nomane district was 4.62 ± 0.42 g/day, and in Sina Sina Yonggomugl district was 6.0 ± 2.61g/day. At measured levels of iodization (mean iodine content 34.7ppm and 32.7ppm respectively), this amount of salt would provide the recommended intake of iodine (150ug/day). However, for children in Karimui-Nomane the median UIC was 17.5µg/L and the interquartile range (IQR) was 15.0 – 43.0µg/L. and in Sina Sina Yonggomugl, the median UIC was 57.5µg/L and the IQR was 26.3 – 103.0µg/L, indicating severe and mild iodine deficiency respectively. These apparently conflicting findings may be explained by the fact that only 34% of households in Karimui-Nomane and 72% of households in Sina Sina Yonggomugl had salt on the day of the survey. The results indicate that iodine deficiency is a significant public health problem in Karimui-Nomane and Sina Sina Yonggomugl districts in Simbu province, potentially because of lack of access to salt, rather than inadequate implementation of salt iodization. Further studies are needed to quantify access to salt for communities in areas that are not easily accessible like Karimui-Nomane district in Papua New Guinea and, if inadequate salt access is confirmed, to develop alternative or complementary strategies to salt iodization.

Keywords: School children, Iodine deficiency, Salt iodization, Urinary Iodine, Simbu province, Papua New Guinea Submitted November 2017, Accepted December 2017 3

Pacific Journal of Medical Sciences, Vol. 18, No. 1, January 2018 ISSN: 2072 – 1625 ======

INTRODUCTION: salt at the households and a set of programmatic Suboptimal intake or low bioavailability of iodine indicators that are regarded as evidence of can cause inadequate production of thyroid sustainability [1, 2]. Due to wide variation in hormones, which are essential for normal growth iodine excretion during the day and in between and development [1, 2]. Iodine deficiency (ID) individuals, UIC cannot be used to assess iodine can lead to mental retardation in infants and status of individuals. The median value of UICs in children whose mothers were iodine deficient a population can however indicate population during pregnancy. ID is also regarded as the iodine status. As a result, median UICs cannot be single most common cause of preventable used to assess the proportion of individuals with mental impairment in communities with iodine deficiency or excess [1, 3]. suboptimal intake of iodine [1, 2]. Marginal degree of ID can affect “apparently healthy” USI was implemented in Papua New Guinea children – the manifestations may include poor (PNG) in June 1995 with enactment of the PNG performance in psychometric tests, and impaired salt legislation, which prohibits the importation mental and motor functions [1, 2]. ID is usually and sale of non-iodized salt [4, 5]. Reports from diagnosed across a target population and not the PNG National Nutrition Survey in 2005 specifically in an individual [2]. indicated that salt was adequately iodized in 92.5% of the households with salt and iodine Universal salt iodization (USI) is the most status among non-pregnant women of child- effective intervention strategy for the control and bearing age was adequate in the four regions of elimination of ID [1 – 3]. The effective PNG [6]. However, 38% of households had no implementation of USI requires continuous salt at the time of the survey, and iodine status monitoring of the process indicator, which is was lower in women from households without availability of adequately iodized salt in the salt [6]. Meanwhile, several sub-national surveys households and the principal impact indicator, carried out from 1998 to 2016 [7 – 14] indicated which is the iodine status, most commonly prevalence of mild to moderate iodine deficiency assessed by measuring iodine concentration of in some districts in PNG. However, no published single urine samples from a representative data was available on the salt iodization and sample of individuals in target populations [1, 3]. status of iodine nutrition in the Simbu province. The sustainability of USI strategy can be assessed by combination of the median urinary The current study was prompted by the report iodine concentration (UIC) in the target presented by the Chief Pediatrician in Simbu population, the availability of adequately iodized (Chimbu) Province during the midyear 4

Pacific Journal of Medical Sciences, Vol. 18, No. 1, January 2018 ISSN: 2072 – 1625 ======consultative meeting of the Pediatric Society of the community. Most of the cases were cretins PNG in 2014 [15]. The focus of the report was without goiter. Thus, because of lack of the nutritional status among infants and children appropriate laboratory services, some of the in Karimui-Nomane district in Simbu province. It diagnoses were confirmed by X-rays showing included cases of cretinism and dwarfism suspected characteristics of cretins. diagnosed based on history taking and clinical Two of the X-rays showed delay in the examinations; several photographs of the development of the carpal bones in the wrist, children and family members were displayed. delay in the development of bone centers of The diagnoses included Failure to Thrive (FTT), ossification indicative of congenital very low IQ, severe stunting, delay dentition, hypothyroidism, pronounced trabeculae in the abdominal distention, umbilical hernia, unable to structure of the metaphyses in the distal end of stand and walk and clinical evidence of the femur and the proximal end of the tibia. The hypothyroidism. The Chief Pediatrician also cited Femoral head center of ossification shows traces suspected cases of congenital hypothyroidism in (Figs 1a and 1b).

Fig. 1a: X-ray of carpal bones in Fig. 1b: X-ray of distal end of femur the wrist [15] and proximal end of tibia [15]

These X-rays are similar to those of patients with exchange for other goods / items and even for hypothyroidism [16, 17]. bride price payments [15]. A similar report was The report further stated that in Karimui-Nomane presented during the midyear consultative district there is a salt water stream that flows out meeting in 2015 because of concerns that no from rocks. The salt water was used to flavour action had been taken [15]. foods by the forefathers of the land, the neighbouring tribes and the whole of Simbu The conclusion of both reports was “an province. Local history indicated that it was a apparently very high prevalence of probably great commodity in the past. It was used in severe iodine deficiency disorders (IDD) exists

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Pacific Journal of Medical Sciences, Vol. 18, No. 1, January 2018 ISSN: 2072 – 1625 ======among the population in Karimui-Nomane district, Kundiawa-Gimbogi district. The specific sites for which is one of the remote districts in the Simbu the study were Karimui-Nomane and Sina Sina province”. An urgent plea was made for Yonggomugl districts. Sina Sina Yonggomugl appropriate scientific investigations to be carried district was assessed in addition to Karimui- out in the district followed by appropriate actions. Nomane as a comparison as it is less remote and mountainous and closer to the capital city [18]. The major objectives of this study were therefore to assess the availability of adequately iodized Sample size for assay of urinary iodine salt in households, the per capita discretionary concentration: intake of salt per day and the iodine status of Calculation of sample size used a design effect school children (age 6 – 12 years) in Karimui- of three, a relative precision of 10%, and Nomane and Sina-Sina Yonggomugl districts in confidence level (CL) of 95% [19]. As there was Simbu province. very limited information on likely prevalence rates of ID in both districts, an assumed prevalence SUBJECTS AND METHODS: rate of 25% was used for each district. With a Study sites: predicted non-response rate of 10%, the sample This study was conducted in the Simbu (Chimbu) sizes of 300 and 250 school-age children were province located in the highlands region in PNG. obtained for Karimui-Nomane and Sina Sina The province has an area of 6,112 Km2 with a Yonggomugl districts respectively. These sample population of about 376,473. It shares sizes were considered adequate for a mini- geographic and political boundaries with five survey with limited resources and also because other provinces: Southern Highland, Jiwaka, of the lack of recent data on the status of iodine Eastern Highland, Gulf and . Simbu is a nutrition among the population in these districts province with very rugged mountainous terrains, and this province. including the tallest mountain in PNG, Mt. Wilhelm, and other notable mountains, like Mt. Study design and sampling: Elimbari, Mt. Digine, and Mt. Crater [18]. The This was a prospective school and community annual rainfall varies between 4,855 mm at high based cross-sectional study. The study altitudes to 1,599 mm at lower altitudes. There population included 6 to 12 years old school are six districts in Simbu province: Chuave, children randomly selected from the primary Gumine, Karimui-Nomane, Kerowagi, Kundiawa- schools in the two districts; seven in Karimui- Gimbogi and Sina Sina-Yonggomugl. The Nomane and three in Sina Sina Yonggomugl. provincial capital is Kundiawa, which is located in Multistage cluster sampling method was used in

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Pacific Journal of Medical Sciences, Vol. 18, No. 1, January 2018 ISSN: 2072 – 1625 ======both districts. The total enrolments in each of the bag. To determine the discretionary intake of salt, selected primary schools, including the ages of sealed packets containing 250g of iodized table children in each of the grades were listed. The salt were distributed to 50 randomly selected required number of children from each of the households in each district. The number of primary schools in each district was selected by individuals living in each household and eating simple random sampling. food prepared in the household was counted and recorded. The head of the household was Salt samples were collected from randomly requested to use the salt as usual for cooking selected households in Karimui-Nomane and and eating. Each household was visited a second Sina Sina Yonggomugl districts. The head of time a few days later to determine the amount of each household was also requested to complete salt remaining in the packet. The number of a questionnaire. The pre-tested questionnaire individuals living in each household was again was used to assess the awareness and use of counted and recorded. The data obtained was iodized salt in the households in both districts. used to estimate the average discretionary intake of salt per capita per day for each district. Collection of samples and questionnaires: Two clean properly labelled sterile containers The major objectives of the study were explained were used to collect water from the salt stream in to the head of each school and to the teachers, Karimui-Nomane district. requesting them to communicate the information The completed questionnaires were also to the parents. Single urine samples were collected from the various households. The salt collected at the school from each of the selected samples, urine samples and questionnaires were school children, after obtaining informed consent appropriately packed into suitable containers and from their parents or guardian. Each urine transported by airfreight to the Micronutrient sample was kept in a properly labelled sterile Research Laboratory (MNRL) in the School of plastic tube with tight fitting stopper that was Medicine and Health Sciences (SMHS) further sealed with special plastic bands. University of Papua New Guinea (UPNG) for analyses. To assess the availability of salt, households were randomly selected from a list of households Exclusion criteria: in both districts. For households with salt All children below 6 years of age and above 12 available at the time of the survey, a teaspoon of years of age were excluded from the study. Urine salt was collected from the salt available in each samples were collected only from children whose household and placed in a labeled zip-locked parents or guardians gave consent.

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Pacific Journal of Medical Sciences, Vol. 18, No. 1, January 2018 ISSN: 2072 – 1625 ======analyses of the data. Shapiro-Wilks test was Analysis of samples: used to assess normality of the data. Mann The iodine content in the salt samples and the Whitney U test was used for differences between water from the salt stream were determined two groups; Kruskal-Wallis and Friedman were quantitatively using the WYD Iodine Checker used for comparison of all groups. Analysis of [20]. Internal bench quality control (QC) for daily variance (ANOVA) was also used to compare routine monitoring of performance characteristics differences between groups. Scheffe test was of the WYD Iodine Checker was by the Westgard used for post-hoc analysis. P < 0.05 was Rules using Levy-Jennings Charts. The percent considered as statistically significant. coefficient of variation (CV) ranges from 2.5% to 5.0% throughout the analysis. The PNG salt legislation was the criteria used for interpretation of the iodine content in salt The UIC was determined by Sandell-Kolthoff samples. According to the legislation all salt must reaction after digesting the urine with ammonium be iodized with potassium iodate; the amount of persulfate in a water–bath at 100°C [1]. iodine in table salt should be 40 – 70ppm Internal bench QC characterization of the assay (mg/kg); the amount of iodine in other salt should method was by the Levy-Jennings Charts and be 30 – 50ppm. This implies that the iodine the Westgard Rules. In addition, the sensitivity content in salt at the time of consumption should (10.0 – 12.50µg/L) and percentage recovery not be less than 30ppm [4, 5]. (95.0  10.0%) of the urinary iodine (UI) assay were frequently used to assess the performance The recommended WHO/UNICEF/ICCIDD characteristics of the assay method. External QC criteria [1] for the interpretation of UIC data were monitoring of the assay procedure was by used to characterize the status of iodine nutrition Ensuring the Quality of Urinary Iodine among the school children in Karimui-Nomane Procedures (EQUIP), which is the External and Sina Sina Yonggomugl districts. According to Quality Assurance Program (QAP) of the Centers the criteria, a population of school-age children is for Disease Control and Prevention (CDC), considered iodine deficient if the median UIC is Atlanta, Georgia, USA. below 100µg/L and iodine sufficient if the median is in the range of 100-200µg/L. In addition, not Data analysis and Interpretation: more than 20% of the urine samples should be Microsoft Excel Data Pack 2010 and the below 50µg/L in an iodine sufficient population. Statistical Package for Social Sciences (SPSS) The median UIC can also be used to indicate the software (version 17) were used for statistical severity of deficiency, for example a population

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Pacific Journal of Medical Sciences, Vol. 18, No. 1, January 2018 ISSN: 2072 – 1625 ======with median UIC <20µg/L is considered severely their employment status, 95.5% (64/67) were deficient and moderately deficient if it is 20- unemployed and 4.5% (3/67) were employed. 49µg/L [1]. One of the major reasons for the low employment rate is because of the remoteness of the district. Ethical Clearance: The participants in Sina Sina Yonggomugl were Ethical clearance and approval for this study comparable except many more were female and were obtained from the SMHS Ethics and less were married. The mean age of all the 25 Research Grant Committee and PNG Medical participants in Sina Sina Yonggomugl was 37.7 ± Research Advisory Committee (PNG MRAC). 13.3 years, age range was 21.0 to 78.0 years Permission was obtained from the appropriate and median age was 35.0 years. There were 7 authorities in Simbu province, Karimui-Nomane (28.0%) male and 18 (72.0%) female district, Sina Sina Yonggomugl district, the participants. 52.0% (13/25) of the participants authorities in the various schools, heads of had primary school level education, 36.0% (9/25) households and the parents of the selected had secondary school level education and 12.0% children. (3/25) completed university. For marital status, 76.0% (19/25) were married, 16.0% (4/25) were RESULTS: single and 8.0% (2/25) were widows. All the 25 Questionnaires: participants were unemployed. No specific A total of 67 households completed the reasons could be given for the low employment questionnaires in Karimui-Nomane district rate. compared to 25 households in Sina Sina Yonggomugl district. Of the 67 participants that Knowledge, awareness and practices related to completed the questionnaires in Karimui-Nomane the use of iodized salt: district, 64.2% (43/67) were males and 35.8 % The participants in the 67 households in Karimui- (24/67) were females. The mean age of the 67 Nomane and the 25 households in Sina Sina participants was 38.0 ±14.2 years, age range Yonggomugl districts stated yes to the question was 16.0 to 70.0 years and median age was 36.0 “Do you use salt at home?” In Karimui-Nomane years. For their level of education, 43.3% (29/67) 14.9% (10/67) used the salt for cooking only, and had secondary school education, 37.3% (25/67) 85.1% (57/67) use salt for cooking and adding to completed university, 16.4% (11/67) completed food before eating. primary school and 3.0% (2/67) could not read or When asked if they use iodized salt at home, write. A total of 98.5% (66/67) of the participants 52.2% (35/67) were positive that they use iodized were married and 1.5% (1/66) was single. For salt at home, 1.5% (1/67) said they do not use

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Pacific Journal of Medical Sciences, Vol. 18, No. 1, January 2018 ISSN: 2072 – 1625 ======iodized salt at home and 46.3% (31/67) was not The participants did not respond to the question sure. 77.6% (52/67) had no knowledge about about the use of traditional salt at home. why it is important to use iodized salt. 34.3% (23/67) said they always purchase salt from the Salt Consumption and Iodization (process local markets, 58.2% (39/67) purchase salt from indicator): the supermarkets, and 7.5% (5/67) purchase Availability of salt in households: from the local markets and trade stores. In each district 50 households participated in this section of the study. Each household was visited When asked how often they eat food from the twice. At the time of the first visit salt was sea, 17.9% (12/67) said frequently, 58.2% available in 17 (34.0%) of the 50 households in (39/67) said once in a while and 23.9% (16/67) Karimui-Nomane district, and in 36 (72.0%) of the admitted that they have never consumed food 50 households in Sina Sina Yonggomugl district. from the sea. None of the participants responded A teaspoon of salt was collected from each to the question regarding the use of traditional household where salt was available. salt, including water from the salt stream. Iodine content in salt from the households: In Sina Sina Yonggomugl district 16.0% (4/25) The summary statistics of the iodine content used the salt for cooking only, and 84.0% (21/25) (ppm) in the salt samples collected from the use salt for cooking and adding to food before households are presented in Table 1. eating. When asked if they use iodized salt at home, The mean (± STD) iodine content in salt samples 92.0% (23/25) were positive that they use iodized from households in Karimui-Nomane was 34.7 ± salt at home, 4.0% (1/25) said they do not use 13.4ppm and the range was 1.9 – 64.7ppm; for iodized salt at home and 4.0% (1/25) was not salt samples from Sina-Sina Yonggomugl the sure if they use iodized salt at home. 88.0% mean iodine content was 32.7 ± 10.5ppm and (22/25) had no knowledge about the use of the range was 2.0 – 62.6ppm. iodized salt. 36.0% (9/25) said they always purchase salt from the local markets and 64.0% The Iodine content was below 30.0ppm in 3 (16/25) purchase salt from the supermarkets and (17.6%) of the 17 salt samples from households other shops. in Karimui-Nomane and 13 (36.2%) of the 36 salt When asked how often they eat food from the samples from households in Sina-Sina sea, all the participants (100%) admitted that Yonggomugl districts indicating that 82.4% and they have never consumed food from the sea. 63.8% of households with salt at the time of the

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Pacific Journal of Medical Sciences, Vol. 18, No. 1, January 2018 ISSN: 2072 – 1625 ======survey in Karimui-Nomane and Sina-Sina Iodine content in water from salt stream in Yonggomugl districts had adequately iodized Karimui-Nomane district: salt. In both districts, the iodine content in was The iodine content was zero in the two water below 15ppm in only one sample. samples collected from the salt water stream in Karimui-Nomane district at the time of this study.

Table 1: Summary statistics of Iodine content (ppm) in salt samples collected from the households in the two districts Parameters Karimui-Nomane Sina Sina Yonggomugl Salt available 17 (34%) 36 (72%) Mean (ppm) 34.7 32.7 Std Dev (STD) 13.4 10.5 95% Confidence Interval (95% CI) (ppm) 27.8 – 41.6 29.2 – 36.3 Range (ppm) 1.9 – 64.7 2.0 – 62.6

Median (ppm) 33.5 33.0 Interquartile Range (IQR) 30.7 – 39.9 27.4 – 36.9 Number (%) of salt with Iodine content<30ppm 3 (17.6%) 13 (36.2%) Number (%) of salt with Iodine content 14 (82.4%) 23 (63.8%) ≥30ppm Number (%) of salt with iodine content 1 (5.9%) 1 (2.8%) <15ppm

Table 2: Summary statistics of the discretionary intake of salt per capita per day in both districts Parameters Karimui-Nomane Sina Sina Yonggomugl N 47 39 Mean (g) 4.62 6.0 Standard Deviation (STD) 0.42 2.61 95% Confidence Interval (95% CI) 3.78 – 5.48 5.15 – 6.85 (g) Range (g) 0.30 – 14.20 1.6 – 11.9 Median (g) 3.80 5.80 Interquartile Range (IQR) (g) 2.80 – 6.75 4.1 – 7.75

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Pacific Journal of Medical Sciences, Vol. 18, No. 1, January 2018 ISSN: 2072 – 1625 ======

Fig. 2: Frequency (%) distribution of the per capita discretionary intake of salt per day in households in Karimui-Nomane and Sina Sina Yonggomugl districts

Discretionary intake of salt per capita per day: The summary statistics of the discretionary intake The frequency distributions of the discretionary of salt per capita per day in Karimui-Nomane and per capita consumption of salt per day in Sina Sina Yonggomugl districts are presented in households in Karimui-Nomane and Sina Sina Table 2. While 50 households in each district Yonggomugl districts are presented in Fig. 2. In were given a package of salt in order to assess Karimui-Nomane district the discretionary discretionary intake, only 47 households from consumption of salt per capita per day was up to Karimui-Nomane and 39 from Sina Sina 5.0g in 66.0% (31/47) of the households Yonggomugl gave permission for the package to compared to 34.0% (16/47) consuming over 5.0g be weighed at the time of the second visit. In of salt. This was in contrast to the results for Karimui-Nomane district the mean per capita households in Sina Sina Yonggomugl where discretionary intake of salt was 4.62 ± 0.42 g/day 33.3% (13/39) of the households were and the range was 0.3 – 14.2 g/day. In Sina Sina consuming up to 5.0g of salt per capita per day Yonggomugl district the Mean was 6.0 ± compared to 66.7% (26/39) consuming over 5.0g 2.61g/day and range was 1.6 – 11.9 g/day. The of salt. Mann-Whitney U and Wilcoxon W tests indicate statistically significant difference (p = 0.01. two- Estimated intake of iodine per capita per day: tailed) between the discretionary daily per capita The mean discretionary intake of salt per capita intake of salt in households in Karimui-Nomane per day in households in Karimui-Nomane district district compared to Sina Sina Yonggomugl was 4.62 ± 0.42g. The mean iodine content in district. Similar results were obtained using the the salt from the households was 34.7 ± Kruskal Wallis and Chi-Square tests (p = 0.011). 13.4ppm. Thus, the calculated mean 12

Pacific Journal of Medical Sciences, Vol. 18, No. 1, January 2018 ISSN: 2072 – 1625 ======discretionary intake of iodine per capita per day Fig 3. The Box-plots show that the UIC (µg/L) was 160.3 ± 14.6µg. Assuming that 20.0% of data were not normally distributed. This was iodine in the salt was lost during storage and confirmed by the Shapiro-Wilks tests (p = 0.001) food preparation, the calculated per capita for normality of distribution. Thus, non-parametric discretionary intake of iodine was 128.2 ± statistics were used for further analysis of the 11.7µg per day. UIC data.

For households in Sina Sina Yonggomugl district, The summary statistics of the UIC (µg/L) for the the mean discretionary intake of salt was 6.0 ± 291 and 253 children in Karimui-Nomane and 2.61g; the mean iodine content in salt was 32.7 ± Sina Sina Yonggomugl districts respectively are 10.5ppm. The calculated mean discretionary presented in Table 3. For children in Karimui- intake of iodine per capita per day was 196.2 ± Nomane the median UIC was 17.5µg/L and the 85.3µg per day. Assuming 20.0% of iodine was interquartile range (IQR) was 15.0 – 43.0µg/L. In lost in the salt during storage and food addition, 97.3% (283/291) of the children had preparation, the calculated per capita UIC less than 100.0µg/L and 77.7% (226/291) discretionary intake of iodine was 157.0 ± had UIC below 50.0µg/L. 68.2µg per day. For the children in Sina Sina Yonggomugl, the URINARY IODINE CONCENTRATION (impact median UIC was 57.5µg/L and the IQR was 26.3 indicator): – 103.0µg/L. 73.1% (185/253) had UIC below For the assessment of iodine status, 301 children 100.0µg/L and 41.5% (105/253) had UIC below were randomly selected from 7 schools in 50.0µg/L. Karimui-Nomane district and 261 children from 3 The Mann-Whitney U and Wilcoxon W tests schools in Sina Sina Yonggomugl district. Casual indicated statistically significant difference (p = urine samples were collected from 293 children 0.001, 2-tailed, Z = - 9.847) between the UIC of in Karimui-Nomane and 252 children in Sina Sina the children in the two districts. This was further Yonggomugl districts. These gave non-response confirmed by the Kruskal Wallis and Chi-Square rates of 2.7% in Karimui-Nomane and 3.4% in tests (p = 0.001). Sina Sina Yonggomugl districts. The median UIC values of 17.5ug/L and 57.5ug/L The distributions of the UIC for the 291 children for the children in Karimui-Nomane and Sina in Karimui-Nomane and 253 children in Sina Sina Sina Yonggomugl districts indicate severe and Yonggomugl are presented in the Box-plots in mild iodine deficiency respectively.

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Pacific Journal of Medical Sciences, Vol. 18, No. 1, January 2018 ISSN: 2072 – 1625 ======

250.0

200.0

150.0

100.0

50.0 Urinary Iodine Conc. (ug/L) Conc. Iodine Urinary

0.0 N = 291 253 Karimui-Nomani Sina Sina Yonggomugl

School Children

Fig. 3: Box-plots of urinary iodine concentrations (µg/L) in school children from Karimui- Nomane and Sina Sina Yonggomugl districts

Table 3: Summary statistics of urinary iodine concentration (µg/L) for the school children in Karimui-Nomane and Sina Sina Yonggomugl districts

Karimui-Nomane Sina Sina Yonggomugl Parameters All children All children (n = 291) (n = 253) Median (µg/L) 17.5 57.5 IQR (µg/L) 15.0 – 43.0 26.0 – 103.0

Mean (µg/L) 33.1 72.5 Std Dev 27.2 83.3 95% CI (µg/L) 29.9 – 36.2 62.2 – 82.8 Range (µg/L) 15.0 – 135.5 15.0 - 217 Percent (n) of children with UIC< 100µg/L 97.3% (283) 73.1% (185) Percent (n) of children with UIC< 50µg /L 77.7% (226) 41.5% (105)

For further analyses of the UIC data the children male and 44.2% (125/283) from female children. were separated according to gender. Gender For urine samples from Sina Sina Yonggomugl was not indicated in 8 (2.7%) of the 291 urine district 56.6% (138/244) from male and 43.4% samples from Karimui-Nomane district and in 9 (106/244) from female children. (3.6%) of the 253 urine samples from Sina Sina Yonggomugl district. Of the urine samples from Fig 4 show the Box-plots for the UIC (µg/L) Karimui-Nomane, 55.8% (158/283) were from obtained for the male and female children in both 14

Pacific Journal of Medical Sciences, Vol. 18, No. 1, January 2018 ISSN: 2072 – 1625 ======districts. The results indicate that the UIC were for the male and female children in Karimui- not normally distributed, which were confirmed by Nomane district. the Shapiro-Wilks tests for normality of distribution (p = 0.001). For the male children in Sina Sina Yonggomugl, the median UIC was 61.3µg/L and the IQR was The summary statistics of the UIC (µg/L) for the 25.1 – 108.1µg/L; for the female children, the male and female children in Karimui-Nomane median was 53.5µg/L and IQR was 26.3 – 93.6 and Sina Sina Yonggomugl districts are µg/L. The UIC for the male children was not presented in Table 4. The median UIC for the significant different (p=0.182, 2-tailied) from male and female children in Karimui-Nomane those of the female children. district was 16.5µg/L and 15.5µg/L respectively; The UIC for the male and female children in the IQR for the male children (15.0 – 42.0µg/L) Karimui-Nomane district were significantly lower was similar to that of female children (15.0 – than the UIC for the male (p = 0.001, 2-tailed) 42.0µg/L). There was no statistically significant and female (p = 0.001, 2-tailed) children in Sina difference (p = 0.751, 2-tailed) between the UIC Sina Yonggomugl district.

Fig. 4: Box-plots of UIC for male and female school children in Karimui-Nomane and Sina Sina Yonggomugl districts Simbu Province

250.0

200.0

150.0

100.0

50.0 Urinary Iodine Conc. (ug/L) UrinaryIodine 0.0 N = 157 125 138 106 Male Karimui Male Sina Sina Female Karimui Female Sina Sina

Male and Female School Children

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Pacific Journal of Medical Sciences, Vol. 18, No. 1, January 2018 ISSN: 2072 – 1625 ======

Table 4: Summary statistics of the UIC (µg/L) for the male and female school children in Karimui-Nomane and Sina Sina Yonggomugl districts

Karimui-Nomane Sina Sina Yonggomugl Parameters Male children Female children Male children Female children (n =158) (n = 125) (n = 138) (n = 106) Median (µg/L) 16.5 15.5 61.3 53.5 Interquartile Range (IQR) (µg/L) 15.0 – 42.0 15.0 – 42.0 25.1 – 108.1 26.3 – 93.6

Mean (µg/L) 32.3 32.9 81.0 63.1 Std Dev 26.0 28.4 105.1 44.0 95% CI (µg/L) 28.2 – 36.4 27.9 – 37.9 63.3 – 98.7 54.7 – 71.6 Range (µg/L) 15.0 – 135.5 15.0 – 132.0 15.0 – 217.5 15.0 – 182.0 Percent (n) of children with UIC below 100µg/L 97.5% (154) 96.8% (121) 67.4% (93) 81.1% (86) Percent (n) of children with UIC below 50µg/L 77.8% (123) 80.0% (100) 37.0% (51) 45.3% (48)

For the male and female children in Karimui- salt may be low in some areas of PNG because Nomane district, median UIC of 16.5µg/L and availability of commercial salt is constrained by 15.5µg/L respectively indicate severe iodine remoteness and distance from ports, as the deficiency and insufficient intake of iodine. For majority of salt is imported, and/or because of the the male and female children in Sina Sina availability of “traditional salt” such as the salt Yonggomugl district, median UIC of 61.3µg/L stream reported in Karimui-Nomane district. and 53.5µg/L respectively indicate mild status According to anecdotal reports, in some areas in iodine deficiency and insufficient intake of iodine. Karimui-Nomane district, two practices are used; water from the salt stream is sprinkled on food for DISCUSSION: taste or grass is soaked in the water from the salt All the participants in both districts that stream then allowed to dry before being completed the questionnaires stated that “they incinerated and the ash used as salt on foods. use salt at home”, supporting the global norm that everyone eats salt, and premise of the salt In households where salt was available however, iodization strategy that salt is a good vehicle for almost all was iodized above 15ppm (94.1% and iodine fortification. However, when asked if salt 97.2% in Karimui-Nomane and Sina Sina was available, only 34% said ‘yes’ in Karimui- Yonggomugl respectively), and the majority was Nomane and only 72% in Sina Sina Yonggomugl. iodized above 30ppm, the national standard This is much lower than the global norm and may (82.4% and 63.8% respectively). Other studies in indicate that salt is less appropriate as a PNG have found similar high rates of adequate fortification vehicle in some areas of PNG. Use of salt iodization in households; 95.0% in Hela

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Pacific Journal of Medical Sciences, Vol. 18, No. 1, January 2018 ISSN: 2072 – 1625 ======district in 2004 [8], 94.5% in National Capital Sina Sina Yonggomugl districts respectively had District (NCD) in 2006 [10], 95.0% in NCD in adequately iodized salt at the time of this study 2009 [11] and 78.0% in Morobe and Eastern [4, 5]. These values are lower than the 90.0% Highlands Provinces in 2013 [12]. recommended coverage of households with adequately iodized salt that should indicate This study found discretionary salt intake to be effective implementation of the USI strategy in relatively low in the two districts studied, at both districts. around 5g per capita per day, compared to an estimated global average of 10.06g [21]. Our data indicate that salt iodization is unlikely to Moreover, this study’s estimate might be an over- be effective in these two districts in Simbu estimation as it is based on the amount of salt province, and indeed, school age children in both consumed from packages provide free to the districts were found to be iodine deficient. Unlike households during the survey. It is possible that in other countries where salt iodization levels and the households may have consumed more than even non-iodization is the limiting factor to they normally would when they have to purchase effectiveness of salt iodization, in PNG the salt themselves. However, studies in other availability of salt may be the limiting factor. Data parts of PNG have also recorded relatively low on salt availability in PNG is limited. As already and even lower salt consumption; 6.59g in reported, 38% of households sampled for the city, [7]; 2.62g in Hela province National Nutrition Survey of 2005 had no salt on [8]; and 4.7g in Morobe and Eastern Highlands the day of the data collection; this proportion was provinces [12]. Nevertheless, despite the low as high as 50% in the Southern region and discretionary salt intake in PNG, at current levels between 32% and 36% in the remaining regions; of iodization, it would provide sufficient amount of it was 42% in rural areas [6]. A survey in iodine of 150ug/person/day [1] to prevent district in found 35% of households deficiency and salt iodization would be expected had no salt in 2015 [14]. Paradoxically, the to be highly effective. National Nutrition Survey found iodine status to However, salt with iodine content above 30ppm be adequate in all four regions of PNG however. was available in only 28.0% (14/50) and 46.0% This may be because while salt was not available (23/50) of selected households in Karimui- in a large proportion of households on the day of Nomane and Sina Sina Yonggomugl districts the survey, it was available in these households respectively. Thus, according to the PNG salt both before and after the day of the survey, i.e. legislation only 28.0% and 46.0% of randomly the whole population is benefiting from salt selected households in Karimui-Nomane and iodization even though there may be days when

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Pacific Journal of Medical Sciences, Vol. 18, No. 1, January 2018 ISSN: 2072 – 1625 ======they have no salt, or the population urinary iodine nutrition in a population because of their easy data, which is based on the median urinary accessibility in the community and the iodine iodine concentration from the whole population, status is assumed to reflect the iodine status of is hiding pockets of deficiency in sub-populations other members of the community [1]. The school- with the lowest availability of salt. based approach was used in this study because of the supposedly high enrolments and The results of this survey, combined with other attendance of both male and female children in data on salt availability and iodine status from primary schools in Karimui-Nomane and Sina PNG, suggest a unique situation and an urgent Sina Yonggomugl districts [1, 15, 18]. need for a better understanding on salt availability and iodine status of sub-populations The response rates of 97.3% and 96.6% in the country if the severe consequences of obtained in Karimui-Nomane and Sina Sina iodine deficiency on the health of the women and Yonggomugl districts are higher than values children [1 – 3] are to be avoided. It may be that reported for similar studies in other districts in for the country as a whole, or for certain sub- PNG [7, 8, 10 – 13]. populations in PNG, salt iodization is not an effective strategy, even when properly The median UIC for the children in Karimui- implemented, and an alternative or Nomane district (17.5µg/L) indicates insufficient complementary strategy to increase iodine intake iodine intake and severe iodine deficiency. For is needed. Potential alternative or the children in Sina Sina Yonggomugl district, the complementary strategies are fortification of an median UIC (57.5µg/L) indicates mild iodine alternative food vehicle, such as rice or wheat deficiency. Thus, iodine deficiency should be flour, [22] or targeted distribution of iodine considered as significant public health problem supplements to high risk groups [24]. It is among schoolchildren, age 6 – 12yrs, in both possible however that those communities in districts at the time of this study. This should be which access to salt is low do not have access to of great concern to program planners in the another processed food that could be a suitable districts, Simbu province, Highlands region and food vehicle for iodization and the lack of roads the National Health Department (NDoH). may also be a limiting factor to achieving high coverage of iodine supplements. The median UIC for children in Sina Sina Yonggomugl was higher than the value reported School children in the 6 – 12 years age group are for schoolchildren in Southern Highlands recommended for the assessment of iodine Province PNG (48.0ug/L) [7], but lower than the

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Pacific Journal of Medical Sciences, Vol. 18, No. 1, January 2018 ISSN: 2072 – 1625 ======value reported in Honduras (287ug/L), Nicaragua deficiency may not be alleviated by improved (259ug/L), El Salvador (251ug/L), Chile implementation of salt iodization or education on (565ug/L), Ecuador (590ug/L), Brazil (1013ug/L) the importance of iodized salt, because neither of and Mexico (1150ug/L) [23]. these strategies will address the fundamental problem of salt availability. Rather, it is necessary In Karimui-Nomane the UIC for 77.8% (123/158) to ascertain the existence of communities whose of the male and 80.0% (100/125) of the female access to salt is so constrained as to make salt children was below 50.0µg/L. These values were iodization ineffective, and, if such communities higher than the 37.0% (51/138) for the male and do exist, to identify alternative or complementary 45.3% (48/106) for the female children in Sina strategies in order to increase iodine intake in Sina Yonggomugl district. The median UIC these communities. values obtained show that the situation in both districts should be considered critical among the ACKNOWLEDGEMENTS: male and female children in the 6 to 12 years age The funding for this project was by the UNICEF groups at the time of this study. The situation is through the Papua New Guinea National more critical in Karimui-Nomane district Department of Health (PNG NDOH). The findings compared to Sina Sina Yonggomugl district. and conclusions in this manuscript are those of the authors; they do not represent the official CONCLUSIONS: position of the institutions and organizations of The present study found low coverage of the authors. We acknowledge the support of the adequately iodized salt and iodine deficiency in Chief Technical Officer and other technical staff school children in two districts of Simbu province, members in the Division of Basic Medical in contrast to the national level data (albeit from Sciences, School of Medicine and Health 2005) indicating adequate iodization levels of salt Sciences, University of PNG. in households with salt, and iodine sufficiency at All the authors declare no conflicts of interest. national level. Rather than suggesting a decline in the iodization situation and a subsequent REFERENCES: decline in iodine status since 2005, we believe 1. WHO, UNICEF, ICCIDD. Assessment of IDD and our present study confirms the existence of some monitoring their elimination: A guide for program mangers 3rd Edition; WHO/NHD/01.1, 2007. communities in PNG which are not easily 2. MB Zimmermann and K Boelaert, Review: Iodine accessible by road and which, therefore, are at deficiency and thyroid disorders www.thelancet.com/diabetes-endocrinology Published high risk of iodine deficiency, because of low online January 13, 2015 http://dx.doi.org/10.1016/S2213-8587(14)70225-6. availability of salt. Unfortunately, the risk of iodine 3. WHO. Guideline: fortification of food-grade salt with iodine for the prevention and control of iodine 19

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